Professional Documents
Culture Documents
Fractures
Definition
• Break in the skin and underlying soft tissue
leading directly into or communicating with
the fracture and its hematoma
History
• Last century, high mortality with open fractures
of long bones
• Early amputation in order to prevent death
• WWI, mortality of open femur fractures > 70%
• 1939 Trueta “closed treatment of war fractures”
– Included open wound treatment and then enclosure
of the extremity in a cast
– “Greatest danger of infection lay in muscle, not bone”
Hampton OP Jr: Basic principles in management of open fractures; JAMA 1955; 159:417-419
History
• Advances shifted the focus
– Preservation of life and limb preservation of
function and prevention of complications
• However, amputation rates still exceed 50% in
the most severe open tibial fractures assoc
with vascular injury*
Lange RH, Bach AW, Hansen ST et al: Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma; 25(3):203-
208
Epidemiology
• 3% of all limb fractures
• 21.3 per 100,000 per year
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
Open fracture classification
• Allows comparison of results
• Provides guidelines on prognosis and
treatment
– Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures
Gustilo and Anderson Classification
• Model is tibia, however applied to all types of
open fractures
• Emphasis on wound size
– Crush injury assoc with small wounds
– Sharp injury assoc with large wounds
• Better to emphasize
– Degree of soft tissue injury
– Degree of contamination
TYPE I OPEN FRACTURE
Type 1 Open Fractures
• Wound less than 1 cm,
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping
http://www.unboundedmedicine.com/2005/11/08/open-fractures-classification-and-its-clinical-manifestations-3/
TYPE II OPEN FRACTURE
Type 2 Open Fractures
• Moderate soft tissue
damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal
stripping
TYPE III-A OPEN FRACTURE
Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle
devitalization
• Bone coverage with
existing soft tissue
TYPE III-B OPEN FRACTURE
Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
• Requires a flap for
bone coverage
and soft tissue
closure
• Periosteal stripping
TYPE III-C OPEN FRACTURE
Type 3c Open Fractures
• High energy
• Increased risk of
amputation and
infection
• Any grade 3 with
major vascular injury
requiring repair
Why use this classification?
• Grades of soft tissue injury correlates with infection
and fracture healing
Grade 1 2 3A 3B 3C
Infection
0-2% 2-7% 10-25% 10-50% 25-50%
Rates
Fracture
Healing 21-28 28-28 30-35 30-35
(weeks)
Amputation
50%
Rate
Gustilo and Anderson
Bowen and Widmaier*
A 0 4%
B 1-2 15%
C 3 or more 31%
Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two
hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162–1166.
So……….
• Fracture type should not be classified in the
ER
• Most reliably done in the OR at the
completion of primary wound care and
debridement
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
Radiological Examination
• Usually, only AP and lateral radiographs are
required
– They should include adjacent joints and any
associated injuries.
• There are a number of features that the
surgeon should look for when examining the
radiographs
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
Radiological Examination
• MRI and CT scans are rarely required in the
acute situation but may be helpful in open
pelvic, intra-articular, carpal, and tarsal
fractures.
• Angiography may be required in Gustilo IIIb or
IIIc fractures.
• In the polytraumatized patient, the surgeon
must decide if a delay for further imaging is
appropriate.
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
Microbiology
• Most acute infections are caused by pathogens
acquired in the hospital
• 1976 Gustilo and Anderson
– most infections in their study of 326 open fxs
developed secondarily
• When left open for >2wks, wounds were prone to
nocosomial contaminants such as Pseudomonas
and other GN bacteria
• Currently most open fracture infections are
caused by GNR and GP staph
Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones; JBJS,
58(4):453-458, June 1976
Nocosomial infection?!!!!
• Only 18% of infections were caused by the
Cover the
same organism initially isolated in the
perioperative cultures*
• Carsenti-Etesse et al. 1999
wounds
– 92% of open fracture infections were caused by
quickly
bacteria acquired while the patient was in the
hospital**
*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res. 1983
Sep;(178):36-41.
*Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing
single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33.
**Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P. Epidemiology of bacterial infection
during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315-23.
Common bacteria encountered with
open fractures
Grade 1
Grade 2 +/-
Grade 3 +/-
Farm/War
Wounds
*Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma.
1983;23:25-30.
**Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized, double-blind study comparing
single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:529-33.
***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ, Shepherd LE, Frenkel B. Inhibitory effects of the quinolone antibiotics trovafloxacin,
ciprofloxacin, and levofloxacin on osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7.
***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander ME, Patel R. Ciprofloxacin inhibition of experimental fracture healing.
J Bone Joint Surg Am. 2000;82:161-73.
When and for how long?
• Start abx as soon as possible*
– Less than 3 hours 4.7 % infection rate
– Greater than 3 hours 7.4%
• No difference btwn 1 and 5 days of post op
abx treatment**
• Mass Gen recommended treatment:***
– Cefazolin Q 8 until 24 hours after wound closed
– Gentamicin or levofloxacin added for type 3
*Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40.
**Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive
antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9.
***Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
Local antibiotic therapy
• High abx conc within the wound and low
systemic conc
– Reduces risk of systemic side effect
• Vancomycin or aminoglycosides
– Heat stable
– Available in powder form
– Active against suspected pathogens
Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-
impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.
Antibiotics - locally
Antibiotic Infection Rate
IV Abx 12%
IV Abx + local aminoglycoside 3.7%
impregnated PMMA beads
Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases; J Bone Joint
Surg Br. 1995 Jan;77(1):93-7.
Antibiotic Beads
• Pros • Cons
– Very high levels of – Requires removal
antibiotics locally – Limited to heat
– Dead space stable antibiotics
management – Increased drainage
from wound
Goals of treatment
• 1. preserve life
• 2. preserve limb
• 3. preserve function
• Also….
– Prevent infection
– Fracture stabilization
– Soft tissue coverage
http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf
Stages of care for open fractures
Initial assessment & management
• ABC’s
• Assess entire patient
• Careful PE, neurovasc
• Abx and tetanus
• Local irrigation 1-2 liters
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.
Initial assessment & management
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the
ED*
– 8% of bugs grown caused deep
infection
– cultures were of no value and not
to be done
• Recheck pulse, motor and
sensation
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.
Primary surgery
*Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310.
**Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30.
Or not?....
Calling the “6 hour rule” into question
• 1993 Bednar and Parikh…. No significant difference *
– 3.4% vs 9%; 82 open femoral/tibial fxs
• 2004 Ashford et al…. No significant difference **
No significant
– 11% vs 17%; pts from the austrailian outback
• 2004 Spencer et al.... No significant difference ***
– 10.1% vs 10.9%; 142 difference
open long bone fxs from UK
• 2003 Pollack and the LEAP investigators…. No correlation****
– 315 open longbefore
bone fxs or after 6
• 2005 Skaggs et al….No significant difference *****
hours!!!
– children with all types of open fractures; 554 open fractures
*Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities
caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.
**Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6.
***Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R
Coll Surg Engl. 2004;86:108-12.
****Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection
after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City, UT.
*****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open
Fractures in Children.” JBJS-A 2005. 87:8-12
Do we even need to do operative
debridement?
• Orcutt et al... No significant difference, BUT…*
– 50 type 1 &2 open
Dofractures
we even
– less infection in nonoperative group (3% vs 6%)
need to debride
– Less delayed union in nonop group (10% vs 16%)
low grade
• Yang et al….0% infections **
open
fractures?
– 91 type 1 open fractures treated without I&D
*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the
Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.
**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res
2003. 410: 289-294.
However, after review of all literature….….
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on
Fracture Healing.” JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial
Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.
How to deliver the irrigation?
(what animal studies show)
• High or low pressure?
– Higher pressure
• Better bone cleaning
• Worse soft tissue cleaning
• Slows bone healing
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on
Fracture Healing.” JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial
Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.
Antibiotics in the irrigation?
• Antibiotics (bacitracin and/or neomycin)
– Mixed results, controversial
– Costly
No proven
• bacitracin alone around $500/washout
– ?? Causing benefit!
resistance
– Wound healing problems?
– Few reported cases of anaphylaxis
– Anglen: “No proven value in the care of open
fracture wounds…some risk, albeit small.”
Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective, Randomized
Study.” JBJS-A 2005. 87(7):1415-1422.
Level 4 evidence based recommendations
Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.
To close or not to close?
• Recently, renewed interest
in primary closure • 1999 Delong et al: 119 open fxs
• Collinge, OTA 2004 – No significant difference
• Moola, OTA 2005 • delayed/nonunion and infection rates btwn
immediate and delayed closure
• Russell, OTA 2005
• DeLong, J Trauma 2004/ – Immediate closure is a “viable option”
• Bosse, JAAOS 2002
– Improved abx management
Grade Percent of primary closures
– Better stabilization
– Less morbidity 1 88%
– Shorter hospital stay, lower 2 86%
cost
– NO increase in wound 3a 75%
infection 3b 33%
• These wounds are at 3c 0%
higher risk of clostridia
perfringens if they do get
infected. infection rate 7%
Overall delayed/nonunion rate 16%
DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture wounds. J Trauma. 1999
Jun;46(6):1049-54.
Contraindications to primary closure
• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment >12 hours
• Delay in giving abx
• Compromised host or tissue viability
When to cover the wound?
• ASAP after wound adequately debrided
– Only 18% of infections are caused by the same organism
isolated in initial perioperative culture*
• Suggests hospital acquired etiology of infection
• Semi-permeable membranes
• VAC
VAC
• Vacuum assisted wound closure
– Recommended for temporary management
– Mechanically induced negative pressure in a closed
system
– Removes fluid from extravascular space
– Reduced edema
– Improves microcirculation
– Enhances proliferation of reparative granulation tissue
• Open cell polyurethane foam dressing ensures an
even distribution of negative pressure
-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11.
-Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in
the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007
Types of fracture stabilization
• Splint
– Good option if operative
fixation not required
• Internal fixation
– Wound is clean and soft tissue
coverage available
• External fixation
– Dirty wounds or extensive soft
tissue injury
Fracture stabilization
• Gustilo type 1 injury can be treated the same
way as a comparable closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts
Fracture stabilization
• Gustilo type 2&3 usually displaced and unstable
– dictate surgical fixation
• Restore length, alignment, rotation and provide
stability
– ideal environment for soft tissue healing and reduces
wound infection
– reduces dead space and hematoma volume
• Inflammatory response dampened
• Exudates and edema is reduced
• Tissue revascularization is encouraged
When to use plates?
• Do these early!
• 1994 Osterman et al.*
Infection risk
– Retrospective 1085 fractures, 115 G2 and 239 G3
increases if wound
• All treated with appropriate IV Abx and I&D
– No infection if wounds closed at 7.6 days
– Yes infection if wounds closed at 17.9 days
open > 7 days
*Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint
Surg Br 1995;77:93–97.
Reconstructive ladder: options for wound
coverage
Primary closure
Type 1 open fx
Secondary intention
Type 2/3A open fx
Skin graft
Local flap
Regional flap
Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combined orthopedic
and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):205-8.
Gunshot injuries
• Energy dissipated at impact = damage
severity
• High velocity rifles and close range
shotguns
– Worst, high energy of impact
– Huge secondary cavitation
– Secondary effects of shattered bone
fragments
• Bullets lodged in joints should be removed
– avoid lead arthropathy and systemic lead
poisoning
Low velocity GSW <2000 ft/sec
• Low velocity handguns
– Less severe, not treated like open fractures
– Cavitation is not significant
– Secondary missile effects are minimal
– Bone fragments rarely stripped of soft tissue
attachments and blood supply
– Soft tissue injuries not severe and skin wounds are
small
Low velocity GSW open fractures
• Geisslar et al. * • Dickey et al.**
• If neurovascular status – No abx vs IV Ancef x 3d
normal, do local Treat open – 67 low velocity GSW fxs
debridement – Not requiring operative
fractures from fixation
low
• NO formal I&D needed
• IV Abx
velocity GSW as
– No difference in
infection rates
closed
• Approach fx fixation as fractures
if closed
without Abx
**Dickey et al, J Ortho Trauma, 3;6-10,1989
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
Thank you